Subarachnoid Hemorrhage Causing a Seizure: An Assessment Simulation for Medical Students

Audience This simulation is intended for 4th year medical students. Introduction Headache is the fifth most common chief complaint in the emergency room, and the vast majority are ultimately diagnosed as benign primary headaches.1,2 However, subarachnoid hemorrhage (SAH) is one of several critical diagnoses which can present as a headache. With a case fatality rate of up to 66.7% in some instances, SAH is considered a “can’t miss” diagnosis.3 Subarachnoid hemorrhage is classically associated with a thunderclap headache, one definition of which is a headache that reaches maximal intensity within one minute or less and reaches a seven out of ten in severity.1 Unfortunately, a thunderclap headache is not as sensitive nor specific for SAH as is often taught. In one study, only 50% of patients with an aneurysmal subarachnoid hemorrhage presented with a thunderclap headache and an additional 19% of SAH headache came on more gradually over the course of five minutes.4 A second study found that only 66% of SAH patients reported a thunderclap headache.2 Thunderclap headaches can also be associated with other intercranial pathology including intracerebral hemorrhage, cerebral venous thrombosis, cervical artery dissection, posterior reversible encephalopathy syndrome, meningitis, and temporal arteritis among others.1,2 In a large observational study, SAH accounted for 32% of the serious pathology cases identified in patients with a thunderclap headache. Even among the thunderclap headache cohort, however, 88% of patients ultimately had a benign diagnosis (compared to 93% of patients who did not report a thunderclap headache).2 Additional signs and symptoms of SAH include seizures in 6–9% of patients, vomiting, neck pain and stiffness, visual disturbances, loss of consciousness, and focal cranial nerve or supratentorial deficits.1,5 A non-contrasted computer tomography (CT) of the head within six hours of headache onset can have a sensitivity of 98.7 to 100%; however, the sensitivity decreased to 86% at the 24–48 hour mark.1,6 A meta-analysis found a pooled six hour sensitivity of 1.0 and asserts that a head CT interpreted as negative by an attending radiologist effectively rules out SAH in neurologically intact patients with a defined onset of a thunderclap headache.6 Some guidelines in the United States still recommend shared decision making with the patient to choose between a Lumbar Puncture (LP), Computer Tomography Angiogram (CTA), or no further testing to rule out SAH in the case of a negative head CT.2 The more time that has elapsed between onset and CT imaging, the stronger the recommendation to pursue further testing. A negative head CT followed by a negative LP approaches 100% sensitivity for ruling out SAH, and a negative head CT with a negative CTA has a 99.4% probability of ruling out SAH.1,3 Thus it is an important learning point that if a headache has been ongoing for more than six hours and there is a high pre-test probability for an SAH, a negative head CT is not sufficient to rule out the diagnosis, and a secondary test should be ordered. Status epilepticus is defined as five minutes of continuous seizure activity or repeated seizures without return to baseline between seizures.7 The immediate priorities for a seizing patient include providing supplemental oxygen, considering intubation if patient is unable to protect airway, obtaining IV access if not previously established, and checking glucose.7 The main priority for a patient in status epilepticus is to stop the seizure with seizure abortive medications, typically benzodiazepines, and treat life-threatening causes of status epilepticus.7 This simulation will enable learners to diagnose SAH that is not the classical “worst headache of my life” and manage an actively seizing patient. Educational Objectives At the conclusion of the simulation leaners will be able to: Efficiently take a history from the patient and perform a physical exam (including a complete neurological exam) Identify red flag symptoms in a patient complaining of a headache Order and interpret the results of a CT of the head and either a CT angiogram of the brain or a lumbar puncture to make the diagnosis of subarachnoid hemorrhage Demonstrate appropriate management of a seizure Check a fingerstick glucose Provide supplemental oxygen Administer an IV or IM benzodiazepine to treat the seizure Utilize the I-PASS framework to communicate with the inpatient team during the transition of care Educational Methods This summative simulation was designed to assess competence in two of the core Entrustable Professional Activities (EPAs), as defined by the Association of American Medical Colleges (AAMC). These include EPA 8 (Give or Receive a Patient Handover to Transition Care Responsibility) and EPA 10 (Recognize a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management). It was performed with 4th year medical students at the conclusion of their required month-long emergency medicine (EM) clerkship. This scenario joined eight other scenarios in our pool of potential cases. These sessions are conducted using a high-fidelity manikin as the patient and a confederate/actor in the nursing role. The students complete the assessment in groups of three or four with each student acting as the team lead for one scenario. After each scenario concludes, there is a post-simulation debriefing session on the presentation, differential diagnosis, physical exam findings, and management of the target pathology. A Gather-Analyze-Summarize technique was used for the debriefing session.8 Research Methods Facilitators provided informal feedback to the scenario developers after the case was introduced into the assessment rotation. Learners completed a standard evaluation issued by the College of Medicine for the entire session rather than for individual scenarios. These evaluations were reviewed for the first year of implementation of this new case. Over the year, 209 students completed the summative simulation exercise, and 84 of those students completed this simulation as part of the overall exercise. Results Overall, our facilitators felt the case fit well into our pool of simulation cases. They felt they were adequately able to assess the students’ ability to respond to a seizing patient and thought the difficulty level was appropriate for fourth year medical students. Students are asked to assess the simulation session as a whole using a standard evaluation form from the College of Medicine. The simulation assessment exercise as a whole was highly rated by the students, with 93% of students rating the overall quality of the session as Very Good or Excellent. Of the students who completed the SAH scenario, 96% rated the overall quality of the session as Very Good or Excellent. None of the comments specifically mention the SAH case. Discussion Our department has run formative simulations during the 4th year EM clerkship for over ten years. Our primary objective is to assess 4th year students’ competence in EPA 10 (Recognize a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management). This simulation case was written to replace another SAH case which was a more straightforward and typical presentation of a subarachnoid hemorrhage as “the worst headache of my life.” The previous case also did not require seizure management. The inclusion of the seizure management better allowed faculty to assess the students’ response to a patient’s acute decompensation, which is more in line with EPA 10, than simply making a critical diagnosis. Our facilitators did notice that many groups initially work the patient up for meningitis but ultimately make the correct diagnosis with the lumbar puncture (LP) results. Because the students have correctly identified that the patient requires more extensive work up, and meningitis is certainly on the differential diagnoses, students are not penalized for following this line of clinical reasoning. This simulation proved to be highly engaging for 4th year medical students, and students seemed to perform at a similar level as previous summative simulations. Overall, we felt this simulation successfully achieved the objectives of the simulation session as whole, and it was integrated into our 4th year EM clerkship simulation curriculum. Topics Medical simulation, Emergency Medicine, Subarachnoid Hemorrhage, Intracranial Hemorrhage, Seizure, Status Epilepticus.

Introduction: Headache is the fifth most common chief complaint in the emergency room, and the vast majority are ultimately diagnosed as benign primary headaches. 1,2However, subarachnoid hemorrhage (SAH) is one of several critical diagnoses which can present as a headache.With a case fatality rate of up to 66.7% in some instances, SAH is considered a "can't miss" diagnosis. 3barachnoid hemorrhage is classically associated with a thunderclap headache, one definition of which is a headache that reaches maximal intensity within one minute or less and reaches a seven out of ten in severity. 1Unfortunately, a thunderclap headache is not as sensitive nor specific for SAH as is often taught.In one study, only 50% of patients with an aneurysmal subarachnoid hemorrhage presented with a thunderclap headache and an additional 19% of SAH headache came on more gradually over the course of five minutes. 4 second study found that only 66% of SAH patients reported a thunderclap headache.2 Thunderclap headaches can also be associated with other intercranial pathology including intracerebral hemorrhage, cerebral venous thrombosis, cervical artery dissection, posterior reversible encephalopathy syndrome, meningitis, and temporal arteritis among others.1,2 In a large observational study, SAH accounted for 32% of the serious pathology cases identified in patients with a thunderclap headache. Een among the thunderclap headache cohort, however, 88% of patients ultimately had a benign diagnosis (compared to 93% of patients who did not report a thunderclap headache).2 Additional signs and symptoms of SAH include seizures in 6-9% of patients, vomiting, neck pain and stiffness, visual disturbances, loss of consciousness, and focal cranial nerve or supratentorial deficits.1,5 A noncontrasted computer tomography (CT) of the head within six hours of headache onset can have a sensitivity of 98.7 to 100%; however, the sensitivity decreased to 86% at the 24-48 hour mark.1,6 A meta-analysis found a pooled six hour sensitivity of 1.0 and asserts that a head CT interpreted as negative by an attending radiologist effectively rules out SAH in neurologically intact patients with a defined onset of a thunderclap headache.6 Some guidelines in the United States still recommend shared decision making with the patient to choose between a Lumbar Puncture (LP), Computer Tomography Angiogram (CTA), or no further testing to rule out SAH in the case of a negative head CT. 2 The more time that has elapsed between onset and CT imaging, the stronger the recommendation to pursue further testing.A negative head CT followed by a negative LP approaches 100% sensitivity for ruling out SAH, and a negative head CT with a negative CTA has a 99.4% probability of ruling out SAH. 1,3 Thus it is an important learning point that if a headache has been ongoing for more than six hours and there is a high pre-test probability for an SAH, a negative head CT is not sufficient to rule out the diagnosis, and a secondary test should be ordered.
Status epilepticus is defined as five minutes of continuous seizure activity or repeated seizures without return to baseline between seizures. 7The immediate priorities for a seizing patient include providing supplemental oxygen, considering intubation if patient is unable to protect airway, obtaining IV access if not previously established, and checking glucose. 7The main priority for a patient in status epilepticus is to stop the seizure with seizure abortive medications, typically benzodiazepines, and treat life-threatening causes of status epilepticus. 7This simulation will enable learners to diagnose SAH that is not the classical "worst headache of my life" and manage an actively seizing patient.
Educational Objectives: At the conclusion of the simulation leaners will be able to: 1. Efficiently take a history from the patient and perform a physical exam (including a complete neurological exam) 2. Identify red flag symptoms in a patient complaining of a headache 3. Order and interpret the results of a CT of the head and either a CT angiogram of the brain or a lumbar puncture to make the diagnosis of subarachnoid hemorrhage 4. Demonstrate appropriate management of a seizure a. Check a fingerstick glucose b.Provide supplemental oxygen c.Administer an IV or IM benzodiazepine to treat the seizure 5. Utilize the I-PASS framework to communicate with the inpatient team during the transition of care Educational Methods: This summative simulation was designed to assess competence in two of the core Entrustable Professional Activities (EPAs), as defined by the Association of American Medical Colleges (AAMC).These include EPA 8 (Give or Receive a Patient Handover to Transition Care Responsibility) and EPA 10 (Recognize a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management).It was performed with 4th year medical students at the conclusion of their required month-long emergency medicine (EM) clerkship.This scenario joined eight other scenarios in our pool of potential cases.These sessions are conducted using a high-fidelity manikin as the patient and a confederate/actor in the nursing role.The students complete the assessment in groups of three or four with each student acting as the team lead for one scenario.After each scenario concludes, there is a post-simulation debriefing session on the presentation, differential diagnosis, physical exam findings, and management of the target pathology.A Gather-Analyze-Summarize technique was used for the debriefing session. 8 Research Methods: Facilitators provided informal feedback to the scenario developers after the case was introduced into the assessment rotation.Learners completed a standard evaluation issued by the College of Medicine for the entire session rather than for individual scenarios.These evaluations were reviewed for the first year of implementation of this new case.Over the year, 209 students completed the summative simulation exercise, and 84 of those students completed this simulation as part of the overall exercise.
Results: Overall, our facilitators felt the case fit well into our pool of simulation cases.They felt they were adequately able to assess the students' ability to respond to a seizing patient and thought the difficulty level was appropriate for fourth year medical students.Students are asked to assess the simulation session as a whole using a standard evaluation form from the College of Medicine.The simulation assessment exercise as a whole was highly rated by the students, with 93% of students rating the overall quality of the session as Very Good or Excellent.Of the students who completed the SAH scenario, 96% rated the overall quality of the session as Very Good or Excellent.None of the comments specifically mention the SAH case.Discussion: Our department has run formative simulations during the 4th year EM clerkship for over ten years.Our primary objective is to assess 4th year students' competence in EPA 10 (Recognize a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management).This simulation case was written to replace another SAH case which was a more straightforward and typical presentation of a subarachnoid hemorrhage as "the worst headache of my life."The previous case also did not require seizure management.The inclusion of the seizure management better allowed faculty to assess the students' response to a patient's acute decompensation, which is more in line with EPA 10, than simply making a critical diagnosis.
Our facilitators did notice that many groups initially work the patient up for meningitis but ultimately make the correct diagnosis with the lumbar puncture (LP) results.Because the students have correctly identified that the patient requires more extensive work up, and meningitis is certainly on the differential diagnoses, students are not penalized for following this line of clinical reasoning.This simulation proved to be highly engaging for 4th year medical students, and students seemed to perform at a similar level as previous summative simulations.Overall, we felt this simulation successfully achieved the objectives of the simulation session as whole, and it was integrated into our 4th year EM clerkship simulation curriculum.

Linked objectives and methods:
Subarachnoid hemorrhage is a life-threatening and time sensitive cause of headache requiring rapid diagnosis and appropriate management.Learners will care for a patient presenting to the Emergency Department with a chief complaint of headache and will have the opportunity to take a history and perform a physical exam (Objective 1).Learners should consider subarachnoid hemorrhage as a potential diagnosis based on the historical features of the headache, including deviation from typical migraine pattern, family history of aneurysms, and absence of a fever (Objective 2).These features should prompt the learners to order a head CT to evaluate for this etiology.When the head CT is negative, they should recognize that, due to the time course (ie, 24 hours since onset of symptoms), the patient requires either a LP or a CT angiogram of the brain to rule out the diagnosis of SAH (objective 3).The patient's clinical status will change from her initial presentation as she has a generalized seizure, for which learners will need to initiate appropriate management, including checking a fingerstick glucose, providing supplemental oxygen, and administering an IV or IM benzodiazepine to treat the seizure.(Objective 4).Finally, learners will need to update the admitting team utilizing the I-PASS framework (Objective 5).
This scenario has been designed to assess competence in two of the core Entrustable Professional Activities (EPAs), as defined by the Association of American Medical Colleges (AAMC).These include EPA 8 (Give or Receive a Patient Handover to Transition Care Responsibility) and EPA 10 (Recognize a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management).These objectives were tracked by facilitators utilizing an institution-specific Employee Performance evaluation form.Facilitators used this form to observe critical actions, mark performance, and take notes during the simulation for further discussion during the debriefing.This scenario joined eight other scenarios in our pool of potential cases.At the end of each four-week clerkship, the learners are split into groups of three or four, and they complete three or four simulation scenarios as a team with each learner serving as the team leader once.These sessions are conducted using a high-fidelity manikin as the patient and a confederate/actor in the nursing role.After each scenario concludes, there is a post-simulation debriefing session on the presentation, differential diagnosis, physical exam findings, and management of the target pathology, with this case being subarachnoid hemorrhage with seizure.A Gather-Analyze-Summarize technique was used for the debriefing session. 8

Recommended pre-reading for instructor:
The instructor should review the management of subarachnoid hemorrhage.One good resource would be "Spontaneous Subarachnoid and Intracerebral Hemorrhage," from the 9 th edition of Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 9Additionally, they should review the management of status epilepticus, the "Guidelines for the evaluation and management of status epilepticus" would be a good reference. 7ther suggested readings include materials listed below in the "References/suggestions for further reading" section.

Objectives:
At the conclusion of this simulation, learners will be able to: 1. Efficiently take a history from the patient and perform a physical exam (including a complete neurological exam) 2. Identify red flag symptoms in a patient complaining of a headache 3. Order and interpret the results of a CT of the head and either a CT angiogram of the brain or a lumbar puncture to make the diagnosis of subarachnoid

Results and tips for successful implementation:
This scenario was developed specifically to replace another case of Subarachnoid Hemorrhage.In the previous scenario, a patient presented to the Emergency Department with the worst headache of their life.This case was more straightforward in terms of presentation (ie, "Thunderclap Headache") and did not require seizure management.The previous case did, however, require anticoagulation reversal.The general consensus among facilitators was that the old case did not appropriately challenge learners because the diagnosis was much clearer than in our other simulation scenarios.The previous case also did not include an acute decompensation of the patient, making it challenging to assess EPA 10.Therefore, the patient in this simulation has a history of migraines of comparable severity and does not consider the presenting headache to be the worst headache of her life.The patient also will not understand what is meant by a "thunderclap" headache if the learners use that verbiage to obtain the history.In addition, while seizure management is not explicitly listed as an expected behavior within EPA 10, our facilitators collectively agreed that the initial management of a seizure was a reasonable expectation for any medical school graduate.Therefore, we took this opportunity to add it to the case because none of other cases review this medical emergency.
Prior to using this scenario as a summative assessment, we ran a single rehearsal session.This included a group of three fourth-year medical students who volunteered to complete an additional simulation case after the completion of their summative simulation session.This group felt the case similar to the other three scenarios they had been given that day and had had equally valuable learning points.No substantial changes were made to the case after this trial run.
Since implementation in May of 2022, our facilitators feel the case fits well into our pool of simulation cases.They report being able to adequately assess the students' ability to respond to a decompensating patient and think the difficulty level is appropriate for fourth-year medical students.
As previously described, all fourth-year medical students at our instiution complete a simulation session consisting of three to four scenarios at the conclusion of the required EM clerkship.
Students are asked to assess the simulation session as a whole using a standard evaluation form from the College of Medicine.
The evaluation form asks students to rate the overall quality of the session, the overall teaching quality of the instructor, and provide one or two things done well in the session and one or two things which could be done to improve the session.The first two questions are answered on a scale of Excellent-Very Good-Good-Fair-Poor.In its first year of use, 84 out of 209 (40%) students completed the subarachnoid hemorrhage scenario as part of their simulation session.The simulation session as a whole is highly rated by the students.The overall survey completion rate was 91%, and the completion rate of the SAH scenario subgroup was 90%.Of the 190 students who completed an evaluation, 93% rated the overall quality of the session as Very Good or Excellent.Of the 75 students in the SAH scenario subgroup who completed an evaluation, 96% rated the overall quality of the session as Very Good or Excellent.None of the collected comments explicitly mentioned the SAH case.

Case Description & Diagnosis (short synopsis):
The scenario begins with the patient presenting to the Emergency Department with a chief complaint of headache.Although the pain will be severe, the patient will be able to have a conversation with the learners and fully participate in a physical exam.After the learners have ordered their tests but before any results are available, the patient will have a generalized seizure.The learners will need to stabilize the patient in order to complete the work-up and make the definitive diagnosis.If not already decided based on the history alone, the seizure should prompt the learners to perform a more extensive work-up for this particular headache.In order to make the correct diagnosis, the learners will need to order either a CT angio study or a lumbar puncture.
Ultimately the patient will be admitted to neurosurgery for operative management.

Actors needed:
One actor in the nursing role.The facilitator will act as the consultant via the overhead speaker: Neurosurgery, Neurology, and/or Pharmacy.The three to four learners will act as Emergency Medicine attendings, with one learner acting as the team leader.

Background and brief information:
The patient is a 28-year-old female presenting to the Emergency Department with a headache.The three to four learners will act as Emergency Medicine attendings, with one learner acting as the team leader.

Initial presentation:
The patient is overall well-appearing.She is alert and oriented, and speaking in full sentences, but clearly uncomfortable from the pain.She is complaining of headache.The onset of symptoms was acute (over a few minutes) and occurred yesterday while she was teaching her kindergarten class.The headache persisted this morning, which prompted her to come to the Emergency Department.She describes the pain as throbbing and rates the pain as 8/10 in severity, but she has had headaches of a similar pain level previously.However, she states that this headache was unique because it happened so quickly, and it involved her entire head.Usually, her migraines only affect the right side of her head.She took her sumatriptan without relief.There are no aggravating or alleviating factors.Upon questioning, she endorses neck stiffness and one episode of non-bloody, non-bilious emesis last night.She denies trauma, fevers, visual changes, weakness, numbness, or difficulty walking.
How the scene unfolds: After the learners place their initial diagnostic and therapeutic orders, the patient will suffer a seizure.The learners will need to stabilize the patient in order to complete the work-up and make the definitive diagnosis.The learners will need to provide supplemental oxygen, obtain a fingerstick glucose, and administer benzodiazepine to stabilize the patient.Without oxygen, the patient will suffer a hypoxic cardiac arrest.Without benzodiazepine, the patient will become comatose.
Once the patient is stabilized, they can turn their attention again to the underlying diagnosis.The red flag features in this case include deviation from her typical migraine pattern, a family history of aneurysms, and eventually the presence of a seizure.These features should prompt the learners to order a head CT to evaluate for this etiology.When the head CT is negative, they should recognize that, due to the time course (ie, 24 hours since onset of symptoms), the patient requires either a lumbar puncture or a CT angiogram of the brain to rule out the diagnosis of SAH.Once the diagnosis of subarachnoid hemorrhage is made, learners should consult neurosurgery and communicate the diagnosis during handoff.The patient should be admitted to the neurosurgery service.

History:
• History of present illness: 28-year-old female who presents with a headache.Patient states that she first noticed the headache yesterday morning.The headache came out of nowhere while she was teaching her kindergarten class about the colors of the rainbow.When she woke up this morning, the headache was still there, which prompted her to come to the Emergency Department.She describes the pain as throbbing and rates the pain as 8/10 in severity, but she has had headaches of a similar pain level previously.However, she states that this headache was unique because it happened so quickly, and it involved her entire head.Usually, her migraines only affect the right side of her head.She took her sumatriptan without relief.There are no aggravating or alleviating factors.Upon questioning, she endorses neck stiffness and one episode of non-bloody, nonbilious emesis last night.She denies trauma, fevers, visual changes, weakness, numbness, or difficulty walking.If the students ask for a neurology consult, the facilitator should call in, hear the story, and say the following: • "I'm busy with stroke alerts, so it will be a minute before I can be there.

Identify subarachnoid hemorrhage (SAH) as a potential diagnosis
a. Subarachnoid hemorrhage is a "can't miss" diagnosis that often presents with a headache.Classically, SAH is associated with a "thunderclap" headache, meaning the headache is very painful and peaks in severity within a minute of onset.Not all patients with SAH, however, report an onset quite this quickly, but 100% of patients in one case-series reported maximal onset within the first hour. 12b.Stiff neck, family or personal hx of aneurysms, and onset with physical exertion are other features that should make the clinician concerned for SAH.c.A normal neurological exam can be falsely reassuring, as up to 50% of patients with SAH have normal neurological exams. 13d.Management of SAH i.Beyond simply consulting neurosurgery, management of SAH is not an emphasis of this simulation because it is beyond the scope of most practicing physicians.However, a quick review of SAH management may be appropriate for groups of learners who have mastered basic treatment concepts.ii.Blood pressure control 1.This is a balancing act between reducing the blood pressure (to reduce the risk of rebleeding), while at the same time ensuring that you are maintaining an adequate cerebral perfusion pressure (MAP-ICP).

A Action List
• Patient is going to need monitoring for seizures, blood pressure control, and ultimately definitive management of her aneurysm.

Situation Awareness and Contingency Planning
• If patient has another seizure or does not regain her mental status within 2 hours, I would consider rescanning her head to evaluate for rebleed.

S Synthesis by Receiver
• From the Facilitator: "So this patient came in with a thunderclap headache, presumably from a subarachnoid hemorrhage, had a seizure, and is now postictal.We will need to monitor her mental status and take her either to the OR or endovascular suite to treat the aneurysm."

54 Subarachnoid Hemorrhage Causing a Seizure Pearls: 1. Efficiently take a history from the patient and perform a physical exam
Go ahead and load her with a gram of levetiracetam.a.When evaluating a patient with a headache, there are several key history and physical exam elements that the student should focus on.These include the time course, severity, and location of the pain; a personal history of headaches, or clotting disorders; whether the patient takes blood thinning medication; a family or personal history of aneurysms; associated symptoms of neck stiffness, fever, vision changes, and neurological deficits.b.The student should perform HEENT and full neurological exams.

Utilize the I-PASS framework to communicate with the inpatient team during the transition of care
2. For most patients, the BP goals should be < 160 mmHg systolic or a MAP < 110 mmHg.a. Illness Severity -Describe whether the patient is stable, unstable, or someone that may decompensate b.Patient Summary -Give a summary statement and explain the hospital course up until now c.Action List -Explain what still needs to be done for the patient d.Situation Awareness And Contingency Plans -Highlight any potential changes that may occur in the patient's clinical status and what could be done if they were to happen e. Synthesis by Receiver-Utilizing closed loop communication, the receiver explains their understanding of the situation to the one giving sign-out f.When reflecting on the sign-out given at the beginning of this case, one can see how unhelpful it was for understanding what is happening with the patient.When looking at the example below, you can understand why this framework is a much more effective form of communication.

PASS Sign-out For Leticia Mendoza-Ruiz
This patient presented with 1 day of a thunderclap headache.Her non-contrasted head CT was normal, but the CT Angiogram showed a 15 mm aneurysm of her anterior communicating artery, so I believe she may have a subarachnoid hemorrhage.She then had a generalized seizure that lasted 3 minutes and aborted with 4 mg of Lorazepam IV.While her mental status is improving, she is not yet back to her neurological baseline.